04120044 CITYBUILDING c DPEReTNN
RAC. l OR TNFURMAT ON
PE WC P - -
euaor"cnooRFss: - CHAMPION PLUMBING PERMIT."°04120044 - -
20054 W
OWNER'S NAME: - PERMIT ISSUE DATE
ED HSIAO
ONE: SANITARY NO. CONTROL NO.
408) 437-1507
;� BUILDING PERMIT INFO
ARCHITF.CTIENGINEER: �J vI BLDG O PLO O r
K. `
up - MSCH
If
LICENSED CO NTR ' DECLARATION Job DBSCn LIOnf
Wreby a nm that 1 am licenq�d proons of Chapter 9(commencing p /i
ith Sect of Division Softh aineuand Pmfminn Cade,and my Bcenm is /y M
m
s Z LI.l a . `H Str: tie:. 1'3ZZ5�p' REPIPE/WATER MAIN OQ
��� _OARCNITECI'SDECLA N
I u d my Plans shall W uarA as bl' sods �JGf j�/ ��J
�� s
Llec fcssianal <
_ �`[�[
.3 ,OWNER-BUILDER DECLARATION ��c�1'r ('j
I 1 hrmhy M.that 1 am exempt from the Coronation's Lianm Lew for the - • — -- -G -----
p O following mason.(Sudan 7001.5,Bnin ss and Professions Code:Any city of county ��/'/,,?- ——
IV
which imur.a permit to construct,sher,improve,demolish,nr rtroh any structure .. V;f,., _
FZ< Pd.,to its issuance.a].mqulru theappliunt fonuch Permit o ties signed r.temem
e thnu
heislicensedposuanttodinpmvisioofthcContractorsLicenselaw(Chapter9 Sq.Ft.Floor Area '*�k-'. 'Valuauon .
$ (rnmmeneingwiN Section7000)or DivtsionJ oflM Businessand Profession Cads)ur -
Nat he I.esrmpt thertfrum and the bask for doe alleged eump0on.My viol"on of
Section 7031.5 by airy appikent(me permit subjects the appllcant to a civil penalty of 3 JA32410anberO 0 Occupancy'Type
nos mom than An hundred della.(5500).
0 1,a inner of the pmpeny,m my employm wW wegu u Nei,sole compenuft, .
willde Hot work.and thestrucare,13 not intended oroffmad lots,].(Sce.70w.Business Required Inspections
and Profession Cade:The Contractor's License Law data not apply m an owner of. - q
property who builds orimprows deacon.and whodmauch work himselfrrthrough his
own employees,provided that such improvements arc not Intended oroRered forrale.If.
however.the Wilding or Improvement is sold within an year of er mpleder,the owner.
Wilder will have tie burden of proving But he did not build or imports for purpose of -
u4.I.
❑1,as owner of the pmMny,am exclusively contracting with licence contracmms w
contract the project(Sec.90x4,Business end Pmfmirn Cede:)The CDn=WeS Il -
cense law dm not apply to an owner of property who Wilds or improves deacon,and
who contcufrkouch projects with acanoacmr(s)licensed pursuant rode Contnnoh _. ." "' — ^_- - .. .. . ... � �•
License La-
0 1.inuencipt under See.
aw.❑1.ineciptunderSee. .B k P C far this mown
Owner Date
WORKERS COMPENSATION DECLARATION
1 hereby Mt under penalty of perjury oro of dte fell.win,declamlon: - -
IhatsandwillmaintainsCenificnscaf Cmnem m self-insum for Worker's Compen-
satirn,u provided for by Section 37M of the labor Code.for the performance of the
work for which this permit is sones.
❑1 eve and will maintain Worker's Compensation Inurwce,as required by Section
37 of de L.Wr Cod..far We pcHoon"Weof Ne wo k fnrwhich this petit is issued.
My orkcYs Comps Ian lnamonce carrier and Po cy number are: ..
�y
'er.jF,4 h rot a.:flioo �&773f2o2
CERTIFICATFOFEKEMPnON FRS'
COMPENSATIONINSURANCE
(Th ssenion recd not W completed if the Petit is Proms hundred dollars($100) -
less.)
1 cenify Not m the performance of IW work fm which Nis Petit is issued.I shall am ,,-
employ any perecn in any mmncr an u in bccome subject o the Workcri Compensation '
Laws of California.Dam
APPliwm - ..
NOTICE TO APPLICANT:Jr.after making dNu Certificate of Escmption,you should
become subject to the Woher's Compcmtum pmvitions of IW labor Code.you most
OQ faMwith comply with such provision at this Petit send W deemed rtwked.
„zi► CONSBUCTION LENDING AGENCY -
(—� Thereby aM.Nat drt.is a contrucfinn lending go.,for the perfarmam:e or
D�.> the.,it far which Nu petit is issued(Sec.3097,Civ,C.)
Qlender's Name
D
z Lead.'a Address
V 0 1 cenify and 1 have read this application and sum that the above information is
U. r correct 1 agree in comply with all city and county onfinances and au¢laws relating m
0 V building construction.and hereby audarm mpmsenu0vo totals city to enter upon dm
[t1 .hove-mentioned propcny for i etionpuryuea
gL c gra to ,ind n fy
and kap hatle s the City of Cupertino ag.iw
y Ila ides,ju menu, as an a hichinayinanywayaccmeagainatuid City eya U z i enampon eofth gm in a is it.
ti
-PLICA UND R A A ILL COMPLY WITH ALL NON-PO Issued by: Date
OU E CU - 1 Z—j-0
Re-roofs
tg u of App is HI, RDOU'LotS M RIMS DISCLOS Data
Type Of Roof -
0r'do applic rfmuac Wil 6rceup.nudre or handle ha.rdous means]
ned by the Cu no Municipa ode.Chapter 9.17,and the Hea ch and Safety
.Section M37( All roofs shall be inspected prior to any roofing material being installed.
❑Ye
Will the applicant or future building occupant use equipment rr devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit W erdnn air emitemin owr as defined by the Bey Ama Air Quality Managcmcm all new materials for inspection.
District
❑rs p�
I have mad the hvalloa.. rials rtquir tsundcr Chapter6.95 of the Glifory
nu Hui ayCodc, ors 05, 533 334.1 undcrsuad am dust Wilding
data a curt rely haw a en ,
a.7
t u my t try b notify IM occvpws of Nc
to ui to whi' cost et ..ism a fa efdfica Ocet xL Signature of Applicant Date
er, authorisJ.gem i Dam All roof coverings to be Class"B"or better
CITY OF CUPERTINO
Saris REPIPE/SEWERS/MAIN SERVICE G
CUPE(TTINO PERMIT APPLICATION FORM
APN# / 7 47 Date:
Building Address:, J
2ps
Own Name: Phone #:
cj( 9=4 A 2 53 — Y6
Co �. License#:
Co Pon Cupertino Business License #:
G - � 26 Z
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ❑
Job Description:
1 1 /I
Residentia � Commercial ❑
Cost of Project:
Qty. if
App c'b Fee ID Fee Description Fee Group
BPERMFEE Bldg. Permit Fees BUILDING
ERMITFEE Plumbing Permit Issuance PLUMBING
PREPIPE Re i e of Fixtures PLUMBING
BPFIXTURE Pbl . Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal_ PLUMBING
BENERGY Energy BUILDING
BUSLIC Business License BUILDING
i